The target volumes for advanced vulvar cancers include the vulva and generally the bilateral external iliac, internal iliac, and inguinofemoral nodal areas, depending on nodal stage and involvement. Patients are set up supine and often in a frog-leg position to minimize skin folds. With 2-dimensional and 3-dimensional planning, vulvar cancer treatment has used an AP/PA field setup. Often, a wide AP and narrow PA field are used, with electrons supplementing the dose to the inguinal region (provided that the nodal depth is within electron range) to limit the dose to the femoral heads.35,39 The use of CT or MRI planning helps ensure adequate dosing of the target volumes, in particular for the inguinal lymph node regions.52 GOG 205 recommended a superior field border of the sacroiliac joints, an inferior border 2 cm below the primary vulvar tumor, and a lateral border to include groin nodes medial to the anterior superior iliac crest bilaterally.48 Patterns of care study from 12 cooperative groups of GCIG reported that the majority of groups use a superior pelvic field border of L4/L5 and that 16 of 18 groups use CT planning.44
The next GOG phase II study (GOG 0279) is building on the success of GOG 0205 neoadjuvant chemoradiation therapy approach by improving the radiation technique approach using IMRT, increasing the radiation dose, and adding gemcitabine to cisplatin in achieving complete pathologic response in the treatment of LRAVC.
Some small institutional studies have suggested that interstitial brachytherapy might be useful for delivering a boost to bulky primary vulvar tumors, for treating recurrences, or for palliation.55,56 The use of interstitial brachytherapy has not been assessed in a randomized controlled study.
Preoperative radiation dose has ranged from 30 Gy in 10 fractions of 3 Gy, 40 Gy in 20 fractions of 2 Gy, 47.6 Gy in 1.7 Gy fractions, and split course to 57.6 Gy in 1.8 Gy fractions in the recent GOG 205.35,45,46,48,57 The GCIG patterns of care study found that neoadjuvant radiation is generally used for unresectable disease or FIGO stage III or above, with most treating the vulva to a dose of 48.2±5 Gy, and that an average neoadjuvant inguinal dose was 49.9±5.5 Gy.44 Increasing dose for neoadjuvant chemoradiotherapy studies has shown improved overall and pathologic complete response rates, and perhaps future studies will help identify subpopulations of patients who can forgo surgery and be treated with concurrent chemotherapy and radiation alone (Table 3).
Although no established standard exists, the majority of the panel supports performing a physical examination every 3 to 6 months for the first 5 years and then annually. Any suspected recurrent or persistent disease should be biopsied. Extrapolating from cervical and anal cancer, PET/CT may be useful for assessing response and monitoring for new distant disease.
* LRAVC can have a variety of presentations, but generally would have significant morbidity if managed with upfront exenterative surgery.
* Whole-body FDG-PET/CT is a useful imaging modality for initial work-up and for assessing response to chemoradiotherapy.
* Standard treatment for LRAVC includes neoadjuvant chemoradiotherapy with weekly concurrent cisplatin, as in GOG 205.
* Radiation should involve CT planning, with treatment volumes including the vulva and the bilateral inguinal and pelvic lymph nodes, preferably with 3D or IMRT.
* In assessing response to neoadjuvant chemoradiotherapy, besides imaging, examination under anesthesia with directed biopsies can be helpful for determining if the patient requires surgery.
* Radiation can also be a useful palliative treatment option for patients with painful vulvar cancer and unable to tolerate more aggressive treatment.
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